Vital Signs

Respiratory Rate Monitoring (breaths/min)

• Documentation requirement: Precise respiratory rate must be recorded at every observation interval.

• Threshold for critical high: Any rate written as > 30 breaths per minute.

• High ranges:

  • $28-29$ breaths per minute.

  • $26-27$ breaths per minute.

  • $20-25$ breaths per minute.

• Intermediate/Normal ranges:

  • $15-19$ breaths per minute.

  • $11-14$ breaths per minute.

• Standard baseline (indicated by 'N'): $8-10$ breaths per minute.

• Threshold for critical low: Any rate written as < 8 breaths per minute.

Oxygen Saturation (%) and Delivery

• Measurement of O₂ Saturation:

  • Optimal range: $98-100\%$.

  • Acceptable/Mildly reduced range: $95-97\%$.

  • Moderately reduced range: $93-94\%$.

  • Low range: $90-92\%$.

  • Critically low range A: $87-89\%$.

  • Critically low range B: $85-86\%$.

  • Threshold for extreme hypoxia: Any value written as $\leq 84\%$.

• Oxygen Delivery Assessment:

  • O₂ Flow Rate: Documentation must include the volume of oxygen delivered in units of $L/min$.

  • Oxygen Delivery Methods (Acronyms):

    • RA: Room Air.

    • NP: Nasal Prongs.

    • HM: Hudson Mask.

    • TS: Tracheostomy.

Blood Pressure (mmHg) Assessment

• Recording methodology: Documentation of systolic and/or diastolic values within specific decade brackets.

• High-end documentation thresholds:

  • Critical high: Write as > 200 mmHg.

  • Ranges: $190s$, $180s$, $170s$, $160s$, $150s$, $140s$, $130s$, $120s$, $110s$, $100s$.

• Low-end documentation thresholds:

  • Ranges: $90s$, $80s$, $70s$, $60s$, $50s$, $40s$.

  • Critical low: Write as < 39 mmHg.

Heart Rate (beats/min) and Rhythm

• Heart Rate Frequency Brackets:

  • Critical Tachycardia: Write as $\geq 140$ beats per minute.

  • High/Normal ranges: $130s$, $120s$, $110s$, $100s$, $90s$, $80s$, $70s$.

  • Low/Bradycardia ranges: $60s$, $50s$, $40s$.

  • Critical Bradycardia: Write as < 39 beats per minute.

• Cardiac Rhythm Documentation:

  • Categorized as either Reg (Regular) or Irreg (Irregular).

Temperature (°C)

• Fever/Hyperthermia Thresholds:

  • Extreme Pyrexia: Write as $\geq 40.0$ °C.

  • High range: $39.0-39.9$ °C.

  • Moderate high range: $38.5-38.9$ °C.

  • Mild fever range: $38.0-38.4$ °C.

• Normothermia and Hypothermia Thresholds:

  • Normal range A: $37.0-37.9$ °C.

  • Normal range B: $36.0-36.9$ °C.

  • Sub-optimal range: $35.5-35.9$ °C.

  • Mild hypothermia range: $35.0-35.4$ °C.

  • Critical hypothermia: Write as $\leq 35.0$ °C.

• General summary flag: $\leq 35 / \geq 40$ indicates a critical intervention point.

Sedation and Pain Scoring

• Sedation Score Definitions:

  • $0$: Wide Awake.

  • $1$: Easy to rouse.

  • $2$: Easy to rouse but unable to stay awake. This score indicates early Opioid-Induced Ventilatory Impairment (OIVI).

  • $3$: Difficult to rouse. This score indicates severe Opioid-Induced Ventilatory Impairment (OIVI).

• Pain Score Scale:

  • Numerical Rating Scale (NRS) from $0$ to $10$.

  • $0$: Indicates No Pain (None).

  • $10$: Indicates the Worst pain imaginable.

Functional Activity Scale (FAS) and Intervention

• Functional Activity Scale (FAS):

  • Documented using qualitative categories: A, B, or C.

• Intervention Recording:

  • Specific clinical interventions should be noted using coded entries (e.g., 'a', 'b', 'c').

Temporal Documentation

• All observations must be anchored to specific metadata for clinical audit trails:

  • Date of observation.

  • Time of observation.